More for less?

At the Barre Family Health Center, Dr. Stephen T. Earls works with Dr. Kathryn J. Wilson on taking the blood pressure of Virginia V. Unitis of South Barre.

An experiment in medical care is rolling out at several Central Massachusetts primary care practices, and it could lead to changes in the way doctors care for patients and get paid.

The Patient Centered Medical Home Initiative aims to put more resources in the hands of primary care practices while also prodding them to build teams to better manage patients and, ultimately, bring down medical spending.

“This lack of coordination that we currently have in the system leads to unnecessary tests, duplicate tests, admissions to the hospital, probably unnecessary nursing home visits,” said Dr. JudyAnn Bigby, state secretary of health and human services. “Paying primary care doctors a bit more and allowing them to design coordinated and managed care for the patients in the practice, we think, will avoid expenses.”

“Medical home” refers to a way of providing comprehensive primary care to patients. Doctors, nurses and others may form teams to manage patients and use electronic technologies to track those patients. Teams also may spend time calling patients, making sure they take medicines, connecting them to help for other problems such as transportation and coordinating with specialists when needed. The focus, supporters say, is on the patient.

The concept has been tested elsewhere.

Blue Cross Blue Shield of North Dakota and a health system tried the concept with 192 patients in 2005 and reported that total costs per member were $530 lower per year than expected. A Colorado program for 150,000 low-income children found costs were $215 lower per child per year than in a group of other children.

In Central Massachusetts, eight organizations will participate in the state's three-year trial of medical homes. Some operate in rural areas, some in urban areas. Officials from some of the organizations say they already try to do some of the things a “medical home” should do. They'll get technical assistance during the trial, plus some additional payments.

The area participants are Barre Family Health Center; Foley Family Practice, Athol; Greater Gardner Community Health Center; Fitchburg Community Health Center; and Family Health Center of Worcester, Edward M. Kennedy Community Health Center, Grove Medical Associates and UMass Memorial Pediatric Primary Care Associates, all of Worcester.

The Barre Family Health Center plans to hire a nurse as a “care manager” to reach out to patients, according to Dr. Stephen T. Earls, medical and education director for the center. The health center, which is part of UMass Memorial Health Care and logs more than 35,000 visits a year from patients in a rural 10-community area, also plans to focus on its patients with diabetes.

That might mean the practice would make sure patients get eye exams, see dentists and check blood sugar regularly. Practices generally may not do that kind of coordination now, because they don't get paid for it by insurers. Instead, they get paid for visits and procedures.

Dr. Earls said the Barre center will also form teams to manage patients' care.

“You'd have the team huddle at the beginning of the session, look at the patients coming in and talking about who needs to do what when the patient is here,” he said. “But the bigger (issue) is what you do when the patient is not coming in.”

Managing ongoing conditions such as diabetes better has the potential to cut medical spending, perhaps by resulting in fewer amputations, heart procedures or blindness treatments, according to Dr. Elizabeth C. Malko, senior vice president and chief medical officer of the Fallon Community Health Plan, a Worcester insurer involved in the medical home trial. But it's not realistic to expect spending to fall quickly, she said.

“Over the short term, you're generally looking to improve satisfaction, to improve quality,” Dr. Malko said. “It takes about 18 to 24 months to make an impact in cost of care.”

The search for ways to bring down health spending is part of the force behind “medical homes,” and it factors into a move toward changing the way doctors and other medical professionals get paid. In Massachusetts, state officials are steering toward “global payments.”

Instead of getting payments for each visit with a patient or procedure, a doctor might be part of a larger network of hospitals and medical professionals that would get a sum of money to provide all or most of the care a patient needs over a period of time.

That lines up with what primary care physicians have been striving to do, said Dr. Ronald N. Adler, director for primary care practice improvement at the Center for the Advancement of Primary Care, a venture of UMass Memorial Health Care and the University of Massachusetts Medical School in Worcester.

“It's no longer driven by the more you do, the more you get paid,” Dr. Adler said.

Others have cautioned that global payments won't help much, however, if medical networks get so big and powerful that they end up demanding bigger payments that drive up spending. Some providers also might be left out of big groups. Patients might even have trouble getting appointments and end up in emergency rooms, according to Dr. Alice A. Coombs, president of the Massachusetts Medical Society.

“It's really important that you not impair access, which indirectly will impact quality,” she said.

Some observers also say “global payments” won't control spending unless doctors and others can make the “medical home” practice work.

“What the medical home will give us is some of the tools to understand what works and what doesn't work so we can participate in a conversation about global payments,” said Frances M. Anthes, president and chief executive of Family Health Center of Worcester Inc., which sees about 22,000 patients a year, many of them poor, at a number of locations in Worcester. “The money savings will probably not be in the primary care arena because we're saying we're going to provide more care.”